AB1758-HPR IDENTIFYING THE RISK OF STEROID INDUCED ADRENAL INSUFFICIENCY IN RHEUMATOLOGY PATIENTS WEANING FROM PROLONGED STEROID THERAPY
Authors: E. Quinlan, M. Khatun, M. Kazmi
Journal: Annals of the Rheumatic Diseases (2023)

<h3>Background</h3> Rheumatologists often prescribe steroids, and long-term use can lead to suppression of the hypothalamic-pituitary-adrenal (HPA) axis, leading to Steroid Induced Adrenal Insufficiency (SIAI). Our departmental guidelines suggest patients on steroid weaning regimes should have morning serum cortisol levels once weaned to 3mg. <h3>Objectives</h3> We aimed to identify what proportion of cortisol levels were abnormal in patients weaning from steroids in various Rheumatological conditions. There are currently no established guidelines to identify patients for possible SIAI, which is usually only assessed if a patient develops steroid withdrawal symptoms at low doses. We wanted to investigate if SIAI was seen commonly and analyse whether patients who had abnormal cortisol levels went on to have a Short Synacthen Test (SST), Endocrinology input and SIAI diagnosis. <h3>Methods</h3> Retrospective review of Rheumatology patients who had morning serum cortisol levels whilst weaning from oral prednisolone at Sheffield Teaching Hospitals. Patients identified via the Clinical Laboratory Database. <h3>Results</h3> Data collected Sept'19 – Oct'22, only samples taken pre-9AM assessed (n=58). 33 Female, 25 Male. Age 21-83 years; mean 65 years. Starting dose prednisolone 5mg-60mg (IQR 15-40mg). Treatment length 6-96 months (IQR 14-48). Samples taken when 84.5% (n=49) taking 3mg, 10.3% (n=6) 2mg and 5.2% (n=3) 2.5mg, (IQR 3mg). Cortisol levels &lt;300 nmol/L in 43.1% (n=25), 300-350 nmol/L in 15.5% (n=9) and &gt;350 nmol/L in 41.4% (n=24). 68% (n=17) of &lt;300 nmol/L (n=25) referred for a SST. SST results were &lt;430 nmol/L in 35.3% (n=6) and &gt;430 nmol/L in 64.7% (n=11). All patients with SST &lt;430 nmol/L (n=6) referred to Endocrinology. 33.3% (n=2) had "borderline" SST results (421nmol/L, 415nmol/L) and advised to wean steroids by 1mg every 4 weeks and discharged. 66.7% (n=4) diagnosed with SIAI, with only one (25%, n=1) having documented symptoms. All (n=4) had further Endocrinology investigation; 100% (n=4) had a repeat SST and pituitary function tests and 75% (n=3) had or awaiting Waking Salivary Cortisol (WSC). 75% (n=3) showed recovery of HPA axis on repeat testing and so advised to slowly wean steroids. 25% (n=1) had persistently abnormal results suggesting ongoing SIAI and advised to remain on 3mg prednisolone. All patients with an abnormal SST (n=6) remained on prednisolone and did not change to hydrocortisone. 90.1% (n=10) of patients with an SST of &gt;430 nmol/L referred to Endocrinology concurrently with SST request and outcome for all patients was to continue slowly weaning steroids. 32% (n=8) patients with a cortisol &lt;300 nmol/L did not have an SST. 37.5% (n=3) had alternative WSC testing; 33.3% (n=1) discharged after normal WSC, 33.3% (n=1) awaiting WSC and 33.3% (n=1) require ongoing Endocrine input as WSC indicated SIAI. This patient awaits steroid clinic and remains on 3mg prednisolone. 62.5% (n=5) had no further investigations. Outcomes: steroids continued by Rheumatology (n=3), steroids weaned by Rheumatology (n=1), too early for further tests (n=1). 15.5% of patients (n=9) had a cortisol between 300-350 nmol/L. None had an SST due to not having symptoms, in line with our guidelines. 33.3% (n=3) had a repeat cortisol, all repeats &gt;350 nmol/L. Outcomes: Rheumatology weaned steroids (n=5), dose increase due to flair (n=2), no further documentation (n=1), moved away (n=1). <h3>Conclusion</h3> 10.3% (n=6) of all patients who had a serum cortisol measurement had an abnormal SST and 8.6% (n=5) of all patients were diagnosed with SIAI. Only one patient had documented symptoms of SIAI. Given the introduction of the more sensitive WSC as an alternative to the SST we aim to modify our department guidelines in collaboration with the Endocrinologists. In line with the 2020 National Patient Safety Association alert and 2022 British Society for Rheumatology guidance the focus is to recognise adrenal insufficiency, which our guidelines are designed to do. Adrenal insufficiency is unpredictable and rare but adrenal crisis can be fatal, so Rheumatologists must be aware of it. <h3>REFERENCES:</h3> NIL. <h3>Acknowledgements:</h3> NIL. <h3>Disclosure of Interests</h3> None Declared.